February 1, 2019
Thomas Flaig, MD
Thomas Flaig, MD

Thomas Flaig, MD, associate dean of clinical research at the CU School of Medicine, is heartened by the American Cancer Society’s report showing the U.S. cancer death rate has declined 27 percent over the past 25 years. But Flaig, who met with members of the African Cancer Coalition in Ghana last summer, says the trend doesn’t necessarily apply to the rest of the world, where cancer remains a huge health issue and is often the first or second leading cause of death.

Flaig, chief clinical research officer of UCHealth, also serves as chair of the National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology Panel for Bladder Cancer. In Ghana, he met with a panel of six African physicians to harmonize NCCN genitourinary cancer treatments for the Sub-Saharan Africa context.

“It was a remarkable experience,” Flaig said. “I found the oncologists in Africa to be extremely well-trained and pragmatic providers working in a different resource environment. It was wonderful to watch them work as a team to harmonize these guidelines to their particular environment.”

In recognition of World Cancer Day, CU Anschutz Today sat down with Flaig to get his views on global cancer trends and challenges that remain in improving cancer mortality rates across the world.

Today: The American Cancer Society has released a report saying that the U.S. death rate from cancer has declined steadily over the past 25 years. What are trends showing when it comes to cancer mortality worldwide?

Flaig: As a practicing oncologist, it’s fantastic to see the death rates from cancer in the U.S., after many years of work, start to come down. What’s also clear – and I think it’s from increasing awareness – is the global attention being paid to cancer. Last year in the world, there were 18 million new cancer cases diagnosed, and 9 million deaths from cancer.

It’s great to see progress being made in the United States. I think that’s credited to all the advances we have in new drugs, in diagnostics, and in all the resources we have here. It’s also clear that those statistics and trend lines don’t necessarily apply to the rest of the world, in which cancer is still a huge burden.

Leading cause of death in nearly 100 nations

Today: What are the reasons for the difference between U.S. and global rates?

Flaig: As has been noted, the death rates for cancer in the United States have come down, and this has been a trend over decades. It’s truly heartening to see this, with all the energy we’ve put into treating cancer in the U.S.

Those same cancer statistics don’t necessarily apply to the rest of the world. In some areas, cancer is typically more common and it’s occurring more frequently in an aging population. Interestingly, as a relative measure, we’ve made more progress in addressing cardiovascular health. So in terms of the incidence of heart attacks and strokes, the death rates have come down, thereby accentuating the need to make more progress on cancer. It becomes a greater health burden, so there’s greater awareness around cancer as a cause of death. If you look at the statistics, there are nearly 100 countries in which cancer is the first or second leading cause of death.

Today: You serve as chair of the NCCN’s Clinical Practice Guidelines in Oncology Panel for Bladder Cancer, and you traveled to Ghana to work with the African Cancer Coalition. What are a few of the key ways that the NCCN is working to support providers and best clinical care in resource-poor countries?

Flaig: The NCCN, of which the University of Colorado is a member, is a wonderful organization which creates a number of guidelines – I think over 50 – which serve as detailed templates for clinicians in how to treat cancer and provides important supportive care around cancer. It’s pretty clear that these guidelines are very much based on resources in high-resource countries like the United States. Last year the NCCN guidelines were downloaded over 10 million times, so it’s also clear that these guidelines are highly utilized across the globe. The guidelines, which are largely focused on the United States, don’t necessarily apply in a medium- or low-resource environment. So, the NCCN has been working hard to essentially harmonize, or adapt, these guidelines to different settings.

I had the great pleasure of traveling to Ghana in 2018 as part of one of these efforts by the NCCN to really look at harmonizing the guidelines for bladder cancer and kidney cancer in the Sub-Saharan African context. For example, we looked at technological resources such as scans – MRIs and CTs – and assessed whether these were regularly available or not. We looked at different drugs, which we use in the American base guidelines, and assessed: do these apply or not?

The NCCN has pursued this work in many different settings. Again, with over 50 guidelines, they’ve picked different parts of the world in which to harmonize or enact these guidelines.

Cancer is becoming a global conversation

Today: Improvements in early detection have led to significant drops in cancer rates in the U.S. What are some of the continuing challenges of treating cancer in developing countries?

Flaig: Cancer is becoming a global conversation. At the American Society of Clinical Oncology (ASCO) meetings, global oncology has become a topic in which there is a lot of interest. More and more sessions are focused on it, and more papers are being written on this topic.

There are clear differences around the globe between the metropolitan areas, which tend to have a higher level of access to tertiary care and technologies, and the rural areas, which often may not. That’s true in the United States, and it’s certainly true in Africa. One of the biggest limitations in developing countries is the resource level. What are they able to provide? What is provided by the government? What’s provided through private insurance?

As you think about access to care in the United States – what’s covered and not covered – these become topics which are, in many cases, national based. One of the key factors in global oncology is understanding what resources are available to prevent and detect cancer in early stages, and how they can be best deployed in individual countries.

Resource and access issues

Today: What drives your interest to work on clinical practice guidelines for cancer treatment globally, and are you optimistic that worldwide cancer mortality will improve similar to the United States?

Flaig: I’m an optimist by nature. It’s really been a pleasure and a great privilege to serve on these guideline committees. When you think about the more than 20 centers (CU Cancer Center among them) that constitute the NCCN, leaders in their respective fields come together on a regular basis to say: what’s the optimal way to treat cancer?

I can say that all who are involved in the NCCN take that responsibility very seriously. I think it’s really important to think about how these guidelines are applied in different settings and what can we do as a guideline committee to essentially adapt these into different environments. My experience in that regard, with the African guidelines, was extremely professionally satisfying.

I enjoyed the chance to work with physicians in a different environment with different pressures. We’ve got our own pressures in the United States, but the physicians in Africa are dealing with resource issues and access issues. Some of the drugs we take for granted in the U.S. they don’t have access to. And then we’re looking at: how can we take all of our collective wisdom and experience and adapt it in a way that can be really useful to a larger group of physicians in a setting such as Africa.

Interest in global cancer topics expands

Today: What are your impressions of efforts such as World Cancer Day? Is it having the desired effect?

Flaig: If I look back over the past few years, I’d say that within the field of oncology in the U.S., the interest in global cancer topics has greatly expanded. On a personal level, this wasn’t necessarily an issue I was thinking about when I was training 10 or 15 years ago. Professional societies have brought these issues forward – ASCO among them – but you can certainly see that as focus on this as a global problem increases, we can learn from each other and we can apply things in different ways.

I also recently traveled to Mexico City and saw oncology care there; it was fascinating to see how a neighboring country dealt with these problems. It’s clear that with cancer, in some ways, it’s not been focused upon in the global sense. We focused on it on a national level, and likely each nation was doing that.

So, it’s great to see what World Cancer Day is doing for the oncology community in terms of focusing on those patients who are being treated in low-resource settings. How can we assist those providers? How can we even promote research to maximize the resources they have in those settings? It’s a rewarding endeavor.

Video by Matt Kaskavitch, Office of Communications

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